AB1589 ESSENTIAL TREATMENT OF RHEUMATOID ARTHRITIS IN ZANZIBAR: A COST EFFECTIVENESS ANALYSIS
Authors: S. Said, B. T. Svanes Fevang, T. W. Nystad, K. A. Johansson
Journal: Annals of the Rheumatic Diseases (2023)

<h3>Background</h3> Rheumatoid arthritis (RA) is a major global health problem and a neglected disease in many developing countries. Health care spending is low in these countries and RA services compete with other important life-saving and effective interventions. Effective therapies for RA are now available which improve overall outcomes and prevent disability especially when initiated early and managed aggressively [1]. All these interventions are available in high-income countries but are sparse in developing countries. There are several health economic evaluations of RA treatment from high-income settings, but few are available or relevant for developing countries. More evidence is therefore needed on the benefits and costs of scaling-up RA services in resource constrained settings. <h3>Objectives</h3> To conduct a cost effectiveness analysis of multiple interventions in the management of RA in Zanzibar. <h3>Methods</h3> A cost-effectiveness analysis for a ten-year duration was conducted from a health provider perspective using a Markov model. Interventions were based on a treat to target strategy with add on therapy or switch to biologic therapy when patients did not reach target (remission or low disease activity). The model compares the efficiency of 'methotrexate monotherapy'(option1), 'methotrexate + sulfasalazine + hydroxychloroquine (triple therapy)' (option 2), methotrexate then biologic 1' (option 2b), 'option 2 then biologic 1' (option 3), 'option 3 then biologic 2' (option 4) and 'option 2b then biologic 2' (option 4b). Data on effectiveness of interventions was obtained from literature. Incremental cost-effectiveness ratios (ICERS) were calculated per quality adjusted life year (QALY) gained from treatment. Staff, building, and utility costs were obtained from the hospital administration records. Drug costs were obtained from the government supplier price list, retail pharmacies and pharmaceutical companies. Mean utility values were calculated from a Zanzibar RA- cohort based on the EuroQol-5D questionnaire responses. Willingness to pay threshold (WTP) was set at 568 USD which is two-thirds of GDP/capita for Tanzania for 2021. We conducted a base case analysis with deterministic sensitivity analysis to explore outcomes with changes in key parameters. <h3>Results</h3> Total costs for the treatment options were largely driven by drugs, predominantly the biologics. The lowest cost was for methotrexate therapy (option 1) at USD 1984/patient/10 years and the highest utilities were gained from treatment with methotrexate therapy + two consecutive bDMARDs (option 4b) (Table 1). Changes in drug costs resulted in significant changes in the ICERs. With variations in the WTP threshold, option 1 remained the most CE to just above USD 2500 where option 2b became the more CE option up to USD 3100 and option 3 became the more CE option. All other options were not considered CE up to 3500 USD. <h3>Conclusion</h3> Methotrexate was found to be the only cost-effective treatment option in our population. Other options although available may be too costly to consider feasible for clinical use unless prices drop. This may be possible via wider availability of biosimilars or via government drug price negotiation to acquire drugs at cheaper costs. <h3>Reference</h3> [<b>1]</b> Smolen JS, Breedveld FC, Burmester GR, Bykerk V, Dougados M, Emery P, et al. Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force. Ann Rheum Dis. 2016 Jan;75(1):3–15. <h3>Acknowledgements:</h3> NIL. <h3>Disclosure of Interests</h3> None Declared.